Common Contracts
4 similar Master Participation Agreement contracts
WESTERN HEALTHCARE INSURANCE TRUSTMaster Participation Agreement • August 21st, 2020
This is an application for (check one): Effective Date: Vimly Account Number (Internal Use Only): Annual Renewal Existing Employer Change New Participating Employer SECTION I: GROUP INFORMATION EMPLOYER INFORMATION Legal Name of Business Doing Business As (DBA) Business Physical Address City: State: Zip: Mailing PO Box City: State: Zip: Federal Tax ID Number State of Legal Domicile Type of Legal Entity Tax Exempt: YES NO Governmental Entity: YES NO Does your group cover Non-Registered Domestic Partners? YES NO We allow the following Domestic Partnerships. Same Sex Opposite Sex Both Group Benefits Administrator (This contact will be the primary contact for benefit updates and administration) Name & Title Phone: Email: Group Billing Administrator (This contact will be the primary contact for billing updates ) Name & Title Phone: Email: Insurance Producer (as applicable) Does your organization use an insurance producer for WHIT plans? YES (if YES, complete the fo
WESTERN HEALTHCARE INSURANCE TRUSTMaster Participation Agreement • September 13th, 2019
This is an application for (check one): Effective Date: Vimly Account Number (Internal Use Only): Annual Renewal Existing Employer Change New Participating Employer SECTION I: GROUP INFORMATION EMPLOYER INFORMATION Legal Name of Business Doing Business As (DBA) Business Physical Address City: State: Zip: Mailing PO Box City: State: Zip: Federal Tax ID Number State of Legal Domicile Type of Legal Entity Tax Exempt: YES NO Governmental Entity: YES NO Does your group cover Non-Registered Domestic Partners? YES NO We allow the following Domestic Partnerships. Same Sex Opposite Sex Both Group Benefits Administrator (This contact will be the primary contact for benefit updates and administration) Name & Title Phone: Email: Group Billing Administrator (This contact will be the primary contact for billing updates) Name & Title Phone: Email: Insurance Producer (as applicable) Does your organization use an insurance producer for WHIT plans? YES (if YES, complete t
WESTERN HEALTHCARE INSURANCE TRUSTMaster Participation Agreement • March 24th, 2016
WESTERN HEALTHCARE INSURANCE TRUSTMaster Participation Agreement • November 9th, 2015
